Effective communication with service · PDF fileEffective communication with service users Ghazala Mir ... effective communication is to be found in wider studies about ethnicity,

Effectivecommunicationwith serviceusers

Ghazala Mir

A Race Equality FoundationBriefing Paper

March 2007

BetterHealthBriefing 2

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Better Health Briefing 2

Effective communication with service users

Key messages

Information about services should be available in a range of languages

and formats

Employing staff from minority ethnic communities at all levels of an

organisation increases cultural competence within it

Families may need to be involved in the communication process

Effective communication requires action at the institutional as well as

individual level

Introduction

Communication between service providers and people from minority ethnic

communities has been highlighted as significant in many studies on

inequalities in health and social care. National policies relating to health

inequalities and to patient choice also emphasise a need for effective

communication between professionals and service users (Department of

Health 2001; 2002). Achieving this policy aim requires an understanding that

expectations and assumptions, which are rooted in values and beliefs, play an

important role in the communication process (Lago and Thompson 1996).

The evidence shows that poor levels of communication have a negative effect

on access to services and on relationships between service users and

professionals. Problems with communication include language barriers and

poor engagement with networks used by minority ethnic groups (Betancourt

et al, 2002). There is also evidence of a lack of confidence or willingness on

the part of both service providers and users to discuss cultural issues that

may be relevant to the way services are provided. For example, how a

personÕs normal diet might fit with a recommended diet; how to take

medication when fasting or travelling abroad; or how language or gender-

related needs might be met (Mir and Din, 2003).

Service providers who are unaware that such issues may be relevant will not

address them. Service users often take the lead from professionals about

what they should discuss and have less power in lay-professional

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Much of the evidence on

effective communication is

to be found in wider

studies about ethnicity,

health and social care.

The following websites

provide a range of

resources that will be

helpful in understanding

how communication

relates to these wider

issues. They also highlight

practical ways in which

professionals have tried to

improve service provision

for minority ethnic

communities.

Kings Fund website

www.kingsfund.org.uk/health_

topics/black_and.html

The KingÕs Fund has a

programme of work

focused on black and

minority ethnic groups that

includes evidence about

inequities in access to

health care.

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relationships. They may also not raise issues that affect them because they

do not expect these to be understood (Mir and Din, 2003).

Failing to communicate effectively can create a vacuum in accurate knowledge

about service users from minority ethnic communities. This can result in

professionals falling back on stereotypes and assumptions that compromise

the quality and effectiveness of services provided. Service users can perceive

poor communication as an apparent disinterest in their welfare, leading to

mistrust of both the service and the provider (Katbamna et al, 2000; Mir and

Din, 2003).

The research evidence on communication is focused mainly on studies in

South Asian populations, and there are gaps in the evidence relating to other

minority ethnic groups. Where studies include a range of communities,

however, common experiences are often found between different

communities.

Information about services should be available in a range of languages

and formats

People from minority ethnic communities are often unaware that services are

available because they have never seen or heard information about them

(Katbamna et al, 2000). Using a single approach to reach minority ethnic

groups does not work for the same reasons it would not work in the general

population. For example, if talks to community groups were the only means

of telling people about a campaign to stop smoking, the information would

reach a relatively small number of people (Mir and Din, 2003), many of whom

might not be smokers, as the majority would not belong to community

groups. Written information, a telephone helpline, outreach activities and a

media campaign could together form a communication strategy that would

be much more effective. As part of this strategy, language support would

need to be addressed (Aspinall and Jackson, 2004). This should include the

language needs of African and Caribbean communities, which are often

overlooked (Robinson, 1998).

Access to written information can be vital. For example, people who have

been newly diagnosed with a heart condition may be given detailed

information packs about how to maintain a healthy lifestyle, to which they

may need to refer at various times. If they are unable to access the

information within it because they cannot read English they are more likely to



Resources 1

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experience complications and earlier mortality (Mir and Din, 2003). Using

translated material in everyday language can remove this barrier to

communication, prevent avoidable suffering and reduce the costs of

healthcare (Katbamna et al, 2000; Mir and Din, 2003; Robinson 2002).

Making English language materials easy to read and including pictures can

also improve access for many people from minority ethnic communities, as

well as people with limited literacy and people with learning disabilities

(Aspinall and Jackson, 2004; Mir et al 2001; Robinson, 2002). Adapting

materials to reflect relevant cultural practices, such as diet, will also help

make them more appropriate (Mir and Din, 2003).

However, if a person is not literate in his or her own language, access to a

professional who can give verbal advice in an appropriate language is needed

(Betancourt et al, 2002). Access to this person should be as easy as

possible and should not rely only on professional referral (Mir and Din, 2003).

Posters, leaflets and outreach activity that advertise this support need to be

made widely available through networks used by minority ethnic

communities. For example, via community centres, places of worship and

local shops, or services used by members of these communities (Aspinall

and Jackson, 2004).

Employing staff from minority ethnic communities at all levels of an

organisation increases cultural competence within it

Research evidence shows that interpreting by family members, rather than

professional interpreters, can result in poor levels of communication with

service users and unethical practices (Mir et al, 2001). Poor practice includes

using children as interpreters or placing an unacceptable emotional burden on

the person doing the interpreting and creating tensions between close

relatives (Katbamna et al 2000).

Dedicated interpreting staff can build up their knowledge of specialist

terminology and develop good knowledge of the service context. However,

professionals need training on how to make the best use of language support

staff (Robinson, 2002). Incorporating an advocacy role into the work of such staff

is empowering for service users and can provide valuable contextual information

to both service users and the professionals who work with them (Betancourt et

al, 2002; Mir and Din, 2003). Staff who act as Ôcultural brokersÕ can increase the

confidence of professionals and service users from different backgrounds to

engage with each other effectively (Mir and Din, 2003; Robinson 2002).

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Organising appointment systems to make the best use of such support

facilities can reduce costs and make the service more accessible to people

who need it (Mir and Din, 2002).

Interpreting is no substitute for direct communication, which is preferred by

professionals and service users alike (Mir and Din, 2002; Robinson, 2002).

Recruiting bilingual staff into mainstream healthcare enables more direct

communication between patients and professionals and can help ensure that

the workforce reflects the population served (Katbamna et al, 2000; Mir et al,

2001). Those who are responsible for such appointments should make sure

they are able to test language ability and that they include skilled people from

relevant communities on appointment panels. Attitudes towards diversity

should be tested in such appointments in the same way as for all staff to

ensure that individuals will help promote good relationships with service users

(Mir and Din, 2003).

Recruiting people to reflect the make-up of the population served can also

improve cultural competence within the organisation. Individuals who have

relevant skills and knowledge in this area can pass these on to colleagues

through informal and formal training and help challenge any stereotypes or

negative attitudes that may exist within service teams (Mir et al, 2001). It

should not be assumed, however, that people will automatically have such

skills just because they are from a minority ethnic community. The grade at

which appointments are made is likely to be a factor in the level of support

that people might need to develop this kind of role (Robinson, 2002).

Increased employment of people from some minority ethnic communities has the

added benefit of addressing the higher unemployment levels they experience.

This strategy communicates powerful message of social inclusion to people from

these groups, including service users. Both employment and social inclusion are

linked to health status and health inequalities (Mir and Din. 2003).

Once people from minority ethnic communities form part of the workforce it is

important to ensure they are properly supported to do the work for which they

have been employed. If they are expected to take on a casework role, it will

be important to make sure they are not the only members of staff dealing with

service users from minority ethnic groups (Betancourt et al, 2002). Otherwise,

service users from these groups may not have access to the full range of

opportunities open to everyone else (Mir et al, 2001). If staff are expected to

take on a strategic role, they will need to be employed at an appropriate grade

and have the authority and connections to make sure a strategy can be

Race for Health

www.raceforhealth.org

Race for Health is a

programme to support a

network of Primary Care

Trusts (PCTs) around the

country, working in

partnership with local black

and minority ethnic

communities to improve

health, modernise services,

increase choice and create

greater diversity within the

NHS workforce. The first

13 PCTs involved are now

being joined by another 13.

Expert Patients

Programme

www.expertpatients.nhs.uk

The Expert Patients

Programme is an NHS self-

management programme

delivered by lay people for

anyone living with any long

term health condition(s).

The aim is to give

participants confidence to

take responsibility for their

own care, while also

encouraging them to work

in partnership with health

and social care

professionals.

Resources 2

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implemented (Betancourt et al, 2002). Giving the strategy a high profile and

training the whole workforce is important so that this is seen as everyoneÕs

responsibility. Use of minority ethnic workers should not be seen as a

substitute for training other staff in cultural awareness (Burford et al, 2000).

Families may need to be involved in the communication process

Engaging with families is important to an accurate understanding of their

circumstances. The myth of extended family support networks for South Asian

people, for example, is perpetuated by agencies failing to investigate the

circumstances of family carers. South Asian families are shown by research to

need family support as much as other families (Ward, 2001; Katbamna et al,

2000).

Family dynamics may need to be addressed when individuals require support to

follow professional advice. For example, where there is poor family support for

changes to diet and lifestyle, investing time to arrive at negotiated ways forward

with key family members could lead to significantly improved support for some

service users (Mir and Din, 2003).

In communities that place a high value on collectivity and interdependence,

families can play a vital role in decision-making. The low status often given to a

collectivist philosophy by mainstream services, however, can place them in

direct conflict with families, hampering trust and the ability to work in partnership

(Bignall and Butt, 2000; Mir et al, 2001).

Access to service provision can be improved through addressing attitudes within

families and communities towards opportunities provided by these services. One

study found that Chinese families associated use of services with poverty and

this perception acted as a disincentive to take-up (Nothard, 1993). There may

be concerns within families about the type of support provided, whether this

would be appropriate in relation to the familyÕs culture or religion, and worries

about the safety of an individual who may be vulnerable (Mir et al 2001; Bignall

and Butt, 2000).

Restrictions by family members are often interpreted as oppressive by service

professionals, and stereotyped images of individuals suffering from Ôculture-

clashÕ may be reinforced when staff feel obstructed by family members. Where

services are modified to address the issues raised by families, however, access

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can usually be improved and family members value the opportunities provided

(Mir et al, 2001). Whereas respecting an individualÕs independence is important,

a focus on independence has sometimes proved to be a convenient pretext for

undermining minority cultures. The key to widening opportunities available to

people from minority ethnic communities lies in respecting cultural identity rather

than in persuading individuals and families that the majority culture is necessarily

better (Mir et al, 2001).

At the same time, respecting cultural diversity should not be confused with

supporting oppressive family practices (Bignall and Butt, 2000). Pursuing a

balanced approach is not easy for professionals but lack of balance can alienate

service users, families or both. It can be helpful for professionals to seek advice

from relevant community organisations, where expertise in culturally appropriate

interventions is most often found (Mir et al, 2001).

Effective communication requires action at the institutional as well as

individual level

At an institutional level, service providers need to ensure that the workforce is

motivated and equipped to communicate effectively with people from minority

ethnic communities. Institutional policies and procedures should be assessed

for their impact on people from these groups (Burford et al, 2000). For

example, procedures to determine the needs of a service user should be

reviewed to ensure these are not culturally biased towards Western lifestyles

and take account of other cultural traditions (Betancourt et al, 2002). Policies

and procedures should demonstrate an expectation of effective

communication skills from staff at all levels and set out opportunities for

training and partnerships that will support the development of this kind of

competence in the organisation (Audit Commission, 2004).

Organisations need to gather information about and from minority ethnic

communities as well as trying to provide information to them. Effective

methods for identifying the needs of people from these communities and

monitoring how well these are met are needed; collecting information about

the make-up of populations served by means of published data and effective

monitoring can highlight which groups an organisation may be neglecting and

which may be over- represented (Audit Commission, 2004). In rural areas,

small populations of people from minority ethnic communities may need

particular attention as they are often dispersed and face greater levels of

neglect (see Rural Diversity website in the Resources column).

Transcultural Health Care

Practice

www.rcn.org.uk/resources/

transcultural

This is an educational

resource for nurses and

health care practitioners.

Ethnicity and Learning

Disability

http://valuingpeople.gov.uk/

dynamic/valuingpeople86.jsp

This website has resources

that can help address the

multiple discrimination that

people with learning

disabilities experience.

Delivering race equality

www.dh.gov.uk

This is a five-year action

plan for tackling

discrimination in NHS and

local authority mental

health services.

Resources 3

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Apart from ethnic group, monitoring the religion and language of service users

can give a fuller picture of potential needs and show whether the workforce

accurately reflects all groups within the local population (Aspinall and Jackson,

2004). It is also vital that service providers consult people from these

populations about the kinds of services they need and ensure they have a

voice in decision making about provision (Betancourt et al, 2002).

Partnerships with voluntary sector organisations that represent the interests of

these groups, can help transfer cultural competence that is often located in

community organisations to mainstream settings. Such groups will need to be

developed in areas where they do not already exist (Mir and Tovey, 2002).

Collecting this kind of information is only really useful if the gaps identified are

then used to inform the commissioning and planning process. Matching

information about needs to commissioning processes effectively targets

resources where they are most needed and can prevent inequalities widening.

It can also prevent expensive mistakes, such as providing resources in

inappropriate languages or employing staff who do not have the skills needed

to engage with communities that need specific targeting (Mir and Din, 2003).

Two important measures of cultural competence within an organisation are

service user satisfaction and service user outcomes (Betancourt et al 2002).

Measuring these across ethnic, religious and language groups can help a

provider understand where future work needs to be targeted (Audit

Commission, 2004). Ensuring complaints procedures are accessible to people

from minority ethnic communities and using information from complaints to

inform service development can improve the quality of health and social care

services and increase the confidence of service users (Mir and Din, 2003). All

publicly funded health care organisations are legally required to have a race

equality policy in place to address these issues, and to review this regularly

(The Stationery Office, 2000).



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Examples of good practice

Equipping staff with relevant skills

Bradford City Teaching Primary Care TrustÕs speech and language therapy

service has therapists specialising in bilingualism. They can deliver support in

Punjabi — the most sought-after of the local community languages — as well as

in Urdu and Bengali. The unit is also developing a capacity for Eastern

European languages.

The service records information on Compact Disc (CD) and audio cassettes to

help families support children with speech and language development. The

CD also explains what speech therapists do so that parents understand the

service before they go to the clinic. Of the unitÕs forty-three staff, thirty are

learning Urdu including managers, therapists and clerical staff, so that they

can effectively deliver the service to people in the local area. Urdu lessons are

tailored to suit therapistsÕ needs and are accompanied by a specially recorded

CD with which team members can practice.

Making services accessible and appropriate

The London Borough of Tower Hamlets recognised that take-up of services by

people with visual impairment from minority groups has been an acute

problem. A study commissioned by the borough found cultural issues needed

to be acknowledged and addressed. The borough appointed a bilingual

development officer who herself had a visual impairment. Her background and

life experience provided a crucial link to the Bangladeshi community.

The project developed outreach activities to give families basic information

about a range of services they could access easily. This developed into weekly

information and advice surgeries and training to community and religious

groups. The improved access to services has at times made huge differences

to the quality of life that people involved with the project experienced.

Rural Diversity

www.ruraldiversity.org/index.htm

This website has

information and resources

on rural race equality.

Further reading

An extensive range of

references and websites

can also be found in:

Bhopal, R. (2007) Ethnicity,

Race and Health in

Multicultural Societies:

Foundations for better

epidemiology, public health

and health care, Oxford:

Oxford University Press.

Resources 4

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Meaningful consultation

Westminster Primary Care Trust (PCT) has set up a Black and Minority Ethnic

Health Forum, an arms-length advisory group which aims to influence both

Westminster and Kensington and Chelsea Primary Care Trusts. The Forum

holds regular meetings with local groups and the two boroughs’ primary care

trusts, hospitals, mental health trusts and social services departments.

Using its links with more than 300 community groups and voluntary agencies

in the local area the Forum has created a new way for the Trust to listen to the

experiences of local black and ethnic minority people. Community groups are

involved in planning and executing the process and have been producing the

results of consultation with service users on mental health services. This

approach worked because people felt the structure and method of

consultation had been decided by them rather than imposed.

People from local groups were offered a two-day training session to equip

them to run the consultation and the PCT provided interpreters and note-

takers as well as meeting rooms and refreshments at the consultation

meetings. The events were used to explore people’s experiences of mental

health services, their attitudes to mental well-being and their access to

information. These were then fed back to the Forum and used to influence

planning decisions within the Trust.

Linking data collection to commissioning

Lambeth PCT has joined forces with the Department of General Practice at

Guy’s, King’s and St.Thomas’ School of Medicine and the South London

Primary Care Research Network to improve data collection of ethnicity, language

and religion in general practices. In one project connected with this exercise,

data gathered will be used to examine the difference in prevalence of psychosis

between the African-Caribbean and general populations. It will look at access to

services and barriers to access and develop service modifications to address

these. In the long run, the PCT hopes to be able to do equity audits on a large

number of health care activities. It expects that in time, lots of small

modifications to services could make a big difference to health outcomes.

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Conclusion

Where attention is paid to effective communication with minority ethnic

service users, substantial progress can be made, as the examples

illustrate. Workforce representation and training, family participation and

institutional policies are needed to achieve levels of communication that

result in access to good quality services. It is important that examples of

good practice become routine and widespread; the costs of problems

caused by poor communication can be high in human terms — and can

lead to expensive litigation (Thorlby and Curry, 2006).

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• Aspinall, P. and Jackson, B. (2004) Ethnic Disparities in Health and Health Care: A focused review and

selected examples of good practice, London: Department of Health/London Health Observatory.

• Audit Commission (2004) Journey to Race Equality: Delivering improved services to local communities,

London: Audit Commission.

• Betancourt, J., Green, A. and Carrillo, J. (2002) Cultural Competence In Health Care: Emerging

Frameworks And Practical Approaches, The Commonwealth Fund.

• Bignall, T. and Butt, J. (2000) Between Ambition and Achievement: Young black disabled people’s views

and experiences of independence and independent living, Bristol: Policy Press/Joseph Rowntree

Foundation.

• Burford, B., Bullas, S. and Collier, B. (2000) Positively Diverse Report 2000, London: Department of

Health/ NHS Executive.

• Department of Health (2000) The NHS Plan. A Plan for Investment. A Plan for Reform, (Cmnd 4818-1),

London: The Stationery Office.

• Department of Health/HM Treasury (2002) Tackling Health Inequalities: Cross Cutting Review, London:

Department of Health/HM Treasury.

• Katbamna, S., Bhakta, P. and Parker, G. (2000) ‘Perceptions of disability and care-giving relationships in

South Asian communities’ in Ahmad, W (ed.) Ethnicity, Disability and Chronic Illness, Buckingham, Open

University Press.

• Lago, C. and Thompson, J. (1996) Race, Culture and Counselling, Buckingham: Open University Press.

• Mir, G. and Din, I. (2003) Communication, Knowledge and Chronic Illness in the Pakistani Community,

Leeds: Centre for Research in Primary Care, University of Leeds.

• Mir, G., Nocon, A. and Ahmad, W. (2001) Learning Difficulties and Ethnicity, London: Department of

Health.

• Mir, G, and Tovey, P (2002) ‘Cultural competency: professional action and South Asian carers’ Journal of

Management in Medicine,16, 1, April, pp. 7-19.

• Nothard, A. (1993) Uptake of services for people with learning disabilities from Black and minority ethnic

communities in Leeds. Leeds: Information and Resources Section, St Mary’s Hospital, Leeds Community

and Mental Health Unit.

• Robinson, L (1998) ‘Race’, Communication and the Caring Professions, Buckingham: Open University

Press

• Robinson, M. (2002) Communication and Health in a Multi-ethnic Society. Bristol: Policy Press.

• The Stationery Office (2000) Race Relations (Amendment) Act 2000, London: The Stationery Office.

• Thorlby, R. and Curry, N (2006) Valuing Equality: paper for the National Race for Health Conference 22-23

November 2006. London: King’s Fund/race for health/NHS

www.kingsfund.org.uk/health_topics/black_and.html (last accessed 6 March 2006).

• Ward, C. (2001) Family Matters: Counting Families In London: Department of Health.

References



Race Equality Foundation

Unit 35

Kings Exchange

Tileyard Road

London N7 9AH

T: 020 7619 6220 F: 020 7619 6230

www.raceequalityfoundation.org.uk

Ghazala Mir is a Senior Research

Fellow and Director of the Ethnicity

Training Network in the Centre for

Health and Social Care at the

University of Leeds. Her research

focuses on inequalities in health and

social care experienced by people

from minority ethnic communities and

people with learning disabilities.

Readers

Sola Afuape

Patricia Chambers

Gary Craig

We welcome feedback on this paper

and on all aspects of our work.

Please email

[email protected]

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Effective communication with service · PDF fileEffective communication with service users Ghazala Mir ... effective communication is to be found in wider studies about ethnicity,